PTSD for PAG Clinicians: Empowering Young Women with PTSD

Transcription

1 PTSD for PAG Clinicians: Empowering Young Women with PTSD Paritosh Kaul, MD 1 Bethany D. Ashby, PsyD 2 Jennifer L. Woods, MD, MS 1 University of Colorado School of Medicine 1 Section of Adolescent Medicine, Department of Pediatrics 2 Department of Psychiatry

2 Learning Objectives At the conclusion of this Workshop participants will be better able to: WJ1 1. Describe the of symptoms of PTSD after sexual assault 2. Discuss the principles for screening for PTSD symptoms in an outpatient setting 3. Outline gynecological concerns among adolescents with PTSD 4. Practice techniques for counseling teens with PTSD in the PAG setting

3 Slide 2 WJ1 Do you want this word capitalized? Woods, Jennifer, 3/2/2017

4 Agenda Describe the symptoms of PTSD after sexual assault Discuss the principles for screening for PTSD symptoms in an outpatient setting Outline gynecological concerns among adolescents with PTSD Practice techniques for counseling teens with PTSD in the PAG setting Case 1 Case 2 Case 3 Debrief Wrap Up

5 Post-traumatic Stress Disorder Criteria Stressor Death/threat of death Serious injury/threat of serious injury Sexual violence/threat of sexual violence Intrusion Thoughts, nightmares, flashbacks Avoidance Thoughts and feelings External reminders

6 PTSD Criteria Alterations in cognition or mood Dissociation Negative distortions (shame, blame) Persistent trauma related emotions Alienation Inability to feel positive emotions

7 PTSD Criteria Alterations in arousal and reactivity Irritability/aggressive behavior Hypervigilance Concentration problems Sleep problems Symptoms last more than 1 month

8 Why screen for PTSD? High rate of sexual abuse and assault Increase in somatic complaints Medical comorbidities Poor treatment response Mental health comorbidities Substance abuse

9 PTSD: Medical Comorbidities Dyspareunia Difficulty with orgasm Pelvic floor dysfunction Vaginal pain

10 PTSD: High-risk Sexual Behaviors More likely to engage in high-risk sexual behaviors than peers with no history of PTSD Higher number of partners 4 times less likely to use condoms 3 times as likely to participate in prostitution Early pregnancy, pregnancy complications Why?

11 PTSD: STIs Higher rates in patients with PTSD than peers with no history of PTSD More likely to be victimized again More likely to forced into/participate in prostitution Abusive partners not allowing contraception

12 Role Play Instructions Step 1: Break into Groups - Break into groups of 3 at your table. - Each of you will take turns playing each of the following parts: Patient Provider Observer Step 2: Start with case 1. You will have 5 minutes for each case.

13 Role Play Instructions Step 3: After each encounter, the group debriefs. - What specific items did the physician do well? - Elicit feedback from the patient s perspective. - What are specific areas of growth and improvement? Step 4: Switch roles. Everyone should play every part for one case.

14 Case 1 AB is an 18-year-old adolescent girl who presents with pelvic pain for 6 months. The history is significant for sexual abuse at age 5 by an older male cousin for which she received psychotherapy for the abuse for about 6 months. Since then, AB has not had any contact with the cousin and reports that this is no longer an issue for her. She became sexually active approximately 6 months ago and has had 1 lifetime partner.

15 Case 1 The abdominal and pelvic examination is normal and screening for sexually transmitted infections (STIs) is negative. AB was reassured and told to take nonsteroidal anti-inflammatory drugs. However, the pain continued and an ultrasound was ordered and revealed few follicular cysts. Due to continued pain, a laparoscopy was performed which revealed no pelvic pathology. AB became frustrated by the negative findings reported increasing anxiety related to the pain. Although she reported that the sexual abuse is not the issue, the clinician decided to screen for posttraumatic stress disorder (PTSD) using the Primary Care PTSD screen due to the patient s history. The screen was positive.

16 Case 1: AB Please share this information with your patient. Questions: 1. How do you best share results of a PTSD screen? 2. How can you explain that pain is real but not necessarily organic in nature?

17 Case 2 Sasha is a 16yo young that presents to clinic requesting a pelvic examination. You review her chart and find that she has been seen on multiple occasions where she has also requested a pelvic exam despite no concern of symptoms (i.e. vaginal discharge, vaginal odor, abdominal pain). Her last STI testing 2 months ago was negative; previous testing performed 4, 6, and 9 months ago was also negative. In further reviewing the chart, you find that Sasha was sexually assaulted by a previous boyfriend 2 years ago.

18 Case 2: Sasha How would you assess for PTSD? How would you talk about PTSD with the patient? What it is? Common symptoms Treatment

19 Case 3 Maria is a 17-year-old female who presents with acute abdominal pain and vaginal discharge. Chart review indicates that she was in foster care between ages and that there is a restraining order in place for her older brother. However, no reason for the restraining order was provided. When asked, Maria states that it was a long time ago and it doesn t matter. You also note that she came in 6 months ago for birth control. Maria refused a pelvic exam at that time and was started on OCPs rather than an IUD which was initially discussed with her. Based on her symptoms, you explain that a pelvic exam is needed to evaluate for abdominal pain and vaginal discharge. Maria becomes visibly anxious and states that she doesn t want a pelvic exam. She asks if you can just give her medicine to treat her symptoms. You again explain your rationale for a pelvic exam and that this is needed before medication can be prescribed. Maria becomes irritated and begins gathering up her things to leave.

20 Case 3 Maria How would you share with Maria that you think that PTSD has a role in her not wanting to have a pelvic examination?

21 DEBRIEF

22 Questions?